Date: ____________________    Annual membership is from date of enrollment.

( ) New Membership        ( ) Renewal

Membership Categories:

( ) Student:* $20 ( ) Individual: $35 ( ) Family: $45

( ) Libraries, museums & historical societies: $35 ( ) Local, state, and county governments: $35 ( ) Supporting: $50

( ) Patron: $100 ( ) Business: $50

( ) Corporate: $100 ( ) Life: $750 and up

* Students: include copy of front and back of student ID card

State Affiliation

Members who live in Lincoln Highway states are automatically members of that state's chapter. Dues for additional chapter memberships are $7.00 per year per state. Check the appropriate box below.

[ ] NY [ ] IN [ ] CO

[ ] NJ [ ] IL [ ] UT

[ ] PA [ ] IA [ ] NV

[ ] WV [ ] NE [ ] CA

[ ] OH [ ] WY

If you would like to serve on a committee, which one?

[ ] Awards [ ] Bylaws [ ] Conference

[ ] Fund Raising [ ] Government Relations [ ] Highway Preservation & Interpretive Sites

[ ] Historic & Contemporary Markers [ ] Historic Resources [ ] Marketing

[ ] Nominating [ ] Public Relations [ ] Headquarters [ ] LHA 2013 Centennial

Please Print

Name ____________________ Address ____________________ City _________ State __ Zip _____

Home phone (__) ___________ Work phone (__) ___________ Fax (__) ___________ E-mail address ______________

What do/did you do for a living? _____________________________________

The Lincoln Highway Association is exclusively charitable and educational, within the interpretation of Section 501(c)(3) of the Internal Revenue Code.

Payment Method:

( ) Check (payable to Lincoln Highway Association)

Credit card: ( ) Visa          ( ) MasterCard Name on card (if other than above): ________________ Address on card (if other than above): ________________ Card number (16 digits): ________________ Expiration Date: ___ / ___ Signature: ________________

Copyright © 1999-2008 by the Lincoln Highway Association.